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5 steps to address social co-morbidities of ill health

As more and more regions look to create and/or expand accountable health communities (which Cambridge Management Group senior advisers have been heavily involved in), this HealthAffairs piece offers five steps to address social co-morbidities of ill health.

They are:

1. “Health Systems Need To Commit To Real Clinical Integration Of Social Needs.”

“One way to achieve clinical integration is by adding some basic fields capturing social needs information into the electronic medical record  — so that providers can approach every clinical encounter with the full set of information they need to understand patients’ health and deliver the highest quality clinical care.”

2. “Commit To Developing A Workforce That Is Truly Focused On Addressing Social Needs.”

It’s critical to have a core group of people whose responsibility it is to come into work every day to assist patients in navigating to the resources they need to be healthy. This cannot be something that is done only in the margins of already busy jobs.”

“This workforce could be community health workers, patient navigators, community resource specialists, or ‘promotoras,’but it could also be some of the hundreds of individuals who volunteer at healthcare institutions.”

3. “Commit To Giving That Workforce The Information They Need To Do Their Jobs Well.”

“A comprehensive, searchable resource database is a necessity. Binders or Excel Spreadsheets last updated in 2011 do not work for information to guide patients’ clinical care, and will not work for their social needs either.”

“Automating resource connections through a technology platform enables clinicians and lay workforces to spend more time building relationships with patients and less time scrambling to find the resources they so desperately need. ”

“Implementations of an integrated, Web-based client management and resource database has demonstrated a 43 percent increase in total resource connections, 55 percent stronger agreement by physicians that their clinic has adequate support to address patient resource needs, and a 60 percent reduction in the time it took to conduct a social needs intake.”

4. “Commit To Follow Up.”

“Efforts to address social co-morbidities are unlikely to be successful if a physician simply tells a patient to eat healthy and exercise more, while ignoring the financial, language, information, and bureaucratic obstacles to making that advice actionable.

Weekly follow-up calls to patients produce a statistically significant increase in the odds of their connecting to the resources they need to be healthy.”

5. “Commit To Collecting And Analyzing Data.”

“As yet, data on patients’ social needs have not been appropriately captured. Physicians know that their patients’ psychosocial needs exist, but are not able to access information about them.”

“As with every other aspect of population health, including implementation of patient-centered medical homes, there will be a period of experimentation and exploration to figure out what works best in which settings. Health-system leaders have been willing to bet on medical homes ahead of such data because the notion of team-based care oriented around patients makes sense.”


Behind the foot-dragging on population health


Barry Ronan,  president and CEO of Western Maryland Health System, in Cumberland, Md., asks whether his colleagues are dragging their feet on moving to population health.

Last year he “defined population health as transitioning care delivery to a model that is valued-based that includes focusing on better case management of those patients with multiple co-morbidities, partnering in care delivery with other providers including previous competitors, better managing overall utilization and caring for patients in the most appropriate setting, not necessarily acute care.”

Mr. Ronan says: “Now with that said, the simple answer to the question in the title is: You bet they are dragging their feet! Neither payment systems nor incentives are aligned in 49 states, and many of the payers have little to no interest in cooperating with providers on population health initiatives.”


“The reason why my colleagues haven’t necessarily gotten on board is very simply that they are still being paid under fee for service. I just read recently about a number of initiatives that are being pursued by CMS related to value-based care delivery, but they are not in place as of yet. In addition, there appears to be little to no support for such initiatives from many of the payers. You shouldn’t expect health systems to change their care delivery model 180 degrees without some form of financial assistance to support infrastructure changes. There is a great deal of upfront cost when such a transition begins.”

“Population health is an all-out change in how care is delivered, and it can be very costly at its inception. Over time, we have saved significant dollars in reduced admissions, readmissions, emergency department visits, observation unit stays and ancillary utilization, but such a change doesn’t occur overnight.”


4 reasons for providers to start insurance plans


Paul Keckley,  managing director of the Navigant Center for Healthcare Research and Policy Analysis,  give four reasons for providers  to start their own health-insurance plans.

But first he notes:

“The most fundamental question facing hospitals and physicians in every community is this: Given the shift in accountability for costs from insurers to hospitals and physicians, does sponsoring a health plan make sense?”

“The bottom line: Physicians, hospitals and post-acute providers are at risk for managing costs and quality. The buck stops there.”

“….Arguably, what’s needed is a financial structure through which efforts to manage the sick efficiently and maintain the health of those who are well can be coordinated. That vehicle is a provider-sponsored health plan.”

Then he gives four good reasons for providers to start health plans;

“1. Mission: Managing total population health is consistent with the role and mission of community-based health organizations. Sponsoring a plan — whether Medicaid, Medicare or commercial — affords a provider organization the mechanism whereby it is able to build and sustain continuous, ongoing relationships with individuals and households (otherwise known as patients). ”

“2. Capability: The management skills, capital, infrastructure and regulatory risk associated with sponsoring a plan can be mitigated through collaboration with  {other} successful provider-sponsored plans. There’s no shortcut to competent administration of a plan, nor is it easy. Nonetheless, it’s been done successfully by many, and their lessons, resources and professionals can be tapped.

“3. Trust: The public trusts hospitals and physicians more than insurers. That does not mean a provider -sponsored health plan can charge significantly higher premiums or offer poor service. It means the community — employers, individuals, legislators and community leaders — will respond favorably if a provider-sponsored plan is offered that’s competitive.”

“4. Timing: The private health insurance industry is at a tipping point. Its margins are at risk. Its traditional market — employers — is becoming more demanding. Its once-soaring profits are shrinking and regulators are watching. As policymakers scrutinize the insurance industry’s consolidation … and as employers seek more value for their premiums, a locally sponsored plan that’s competitive on premiums and plan design with clear alignment to the local provider community is worth discussion, especially if its financial performance is tied directly to the community’s benefit rather than insurer shareholder value.”


Healthcare IT in 2016


This article  by John Halamka in tech-focused MedCity News makes predictions for health IT in 2016. They include, here in stripped-down form:

1. “Population health will finally be defined and implemented.”

2. “Security threats will increase.”
3. “The workflow of EHRs will be re-defined. ”

4. “Email will gradually be replaced by groupware.”

5. “Market forces will be more potent than regulation.”

6. “Apps will layer on top of transactional systems empowered by FHIR {Fast Health Interoperability Resources}.”

7. “Infrastructure will be increasingly commoditized.”

8. “Less functionality with greater usability will shape purchasing decisions.”

9. “The role of the CIO will evolve from provisioner/tech expert to service procurer and governance runner.”

10. “The healthcare industry will realize that IT investments must rise for organizations to meet customer expectations, survive bundled payment reimbursement methods, and create decision support/big data wisdom.”


Video: New IHI head talks about the key to population health

In this Hospitals & Health Networks video, Derek Feeley, the incoming head of the Institute for Healthcare Improvement, talks about the key to better population health.




More health systems move into social initiatives


Herewith a  national look at how some hospitals systems  are working to promote social initiatives to improve population health and cut the astronomical cost of healthcare.Cambridge Management Group has long been working in the field of social determinants of health, most  recently in its recent engagement with Jackson Care Connect, in Oregon.

As Modern Healthcare notes: “A small but growing group of not-for-profit hospitals and health systems is spending more money on nontraditional community benefit programs designed to address social determinants that affect health, including crime, education, housing, hunger, jobs, poverty and violence.

“Many of these projects fall outside the conventional range of community benefit activities, such as free clinics and health screening events. Instead, their focus is on building healthier communities by bettering people’s lives. ”

There are some high hopes, but some public-health experts say that community health improvement initiatives might take as long as a generation to make a significant impact, and get a good return on investment for health systems.

As Modern Healthcare noted: “{S}ome researchers question whether these efforts by health systems will be big enough to dent broad societal problems such as poverty and income inequality, and whether the systems are willing to step into controversial political fights that could involve government spending and regulation. Health systems are still trying to gather the evidence that their programs are having the intended impact.”

“Increasing access to medical care is less important to health outcomes than addressing social factors such as income inequality and support for parents during the first year of a child’s life, Stephen Bezruchka, M.D., a senior lecturer in the health-services department at the University of Washington, told Modern Healthcare. “You have to recognize that nonmedical factors are what produce health. {But} I don’t see any hospitals trying to advocate for social change.”


H&HN video. Working with public health departments on population health

Varsa Health’s platforms link BH patients, PC providers


Varsa Health has some intriguing  pilot programs dealing with population health. It’s particularly interested in new approaches to behavioral health, especially in finding ways to link behavioral-health specialists and care managers to primary-care providers.

One example from MedCity News of its approach is academic medical center using “Varsa Health’s platform to identify young adults at risk for behavioral health problems such as depression and anxiety. Patients are either directed to a kiosk within a provider’s office or are connected to a Web site through a mobile phone, tablet or computer. Users receive feedback based on their responses through short multimedia content tied to their health status. Care teams receive notifications for patients at an elevated risk for a behavioral health condition based their responses on the questionnaire.”

“Another pilot includes a rural health system with a patient population dominated by people with serious mental illness. The idea is to reduce the gaps in follow-up care for its patients. Through mobile devices from patients or provided by case managers doing home visits, patients will be prompted to give outcomes data in a digital format. The idea is to gather information about patients’ health status from their perspective.”


Five levels in improving population health



Tom Frieden, M.D.,  director of  the Centers for Disease Control and Prevention, writes in The New England Journal of Medicine that providers must deal with five levels of a “pyramid” model to optimize public health.

He lists:

  • The base: socioeconomic determinants — income, employment status, race and education,  followed by, in this order:
  • Such public-health interventions as expanded health coverage or contraception access.
  • Long-term preventive interventions, such as immunizations.
  • Clinical interventions such as blood-pressure management.
  • Public education and outreach efforts.

Dr. Frieden says that major long-term population-health improvement depends on preventive and clinical interventions.

Some key elements in successful population-health initiatives include, he says:

  • Team-based care.
  • Patient-centered care.
  • Consistency.
  • Continual improvement in delivery and treatment.
  • Registry-based information systems.

Using modeling to improve population health



“Modeling in science” by Marcello Donatelli – Own work. Licensed under CC BY-SA 3.0 via Commons 

This report about a workshop last spring, which we spotted on the Institute of Medicine’s Web site, looks into how modeling can inform strategies to improve population health.

A summary says:

“The health sector has a growing need to use modeling to inform policy decisions and for selecting and refining potential strategies (e.g., ranging from interventions to investments) to improve the health of communities and the nation. Modeling has been used across many disciplines to assist in the development of public policy decisions for decades. A growing interest in systems science approaches to population health has led public health researchers, regulators and others to turn to modeling more than ever, and many types of models have been used to forecast health effects associated with current and future risk behaviors. …To explore how modeling can inform strategies to improve population health, the Roundtable on Population Health Improvement held a public workshop on April 9, 2015, that featured a number of presentations and discussions, beginning with an overview of how modeling has been applied in multiple fields to inform policymaking and followed by an in-depth exploration of several examples and potential future uses of modeling.

The day included dialogue between modelers from a range of disciplines and model users with a focus on making practical contributions to move modeling forward in population health at the local, state, and federal levels, including strategies to build capacity for modeling.

See this link.


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